2.0 Analysis 2.1 Introduction Given that the available evidence indicates that the crews of both vessels had the appropriate qualifications and experience, the analysis focuses on why the operating practices in effect at the time of the collision were perceived to be appropriate. The analysis also deals with the available evidence regarding the fitness for duty of the navigating personnel and any potential impact on the operation of the vessels. 2.2 Expectations and Operating Practices 2.2.1 General There is evidence in the operating practices of both vessels that neither vessel expected to encounter another vessel in the area. Operating procedures, amounting to system defences against just such incorrect expectations, have been developed, particularly for the type of weather conditions encountered. These procedures involve the use of appropriate signals, electronic navigational systems, look-outs and speeds. In this case, the approved operating procedures were not followed, in varying degrees, on either vessel. 2.2.2 GRIFFON 2.2.2.1 Operation The GRIFFON was directed by the master to operate at full service speed; a bow look-out was not designated, and direction was given not to sound the fog signals. In addition, the lack of radio security calls and of effective BRM on the part of the GRIFFON, including the non- utilization of a blind pilotage regime and crew briefings, further reduced system effectiveness. The master's disabling of system safety measures is consistent with a mental model that precluded the likelihood of meeting other traffic en route. While the master was familiar with the area and was aware that a fleet fished out of Port Dover, it appears that he did not expect the fleet to be operating. The master's perception that there was a requirement to complete the task so that overtime was minimized and so that the impending worsening weather was avoided may have worked to prevent him from considering that these actions were not prudent. Stress may also have narrowed the scope of the master's focus and affected his judgement such that he ordered the vessel to proceed at speed, before the collision, without taking adequate safety precautions under the circumstances. So robust was his mental model that, on hearing the noise of the collision, the master assumed that the deck crew had dropped a buoy on to the deck; it took the actual sighting of the CAPTAIN K through his porthole to cause the master to reexamine his premise. 2.2.2.2 Bridge Resource Management (BRM) The manner in which the GRIFFON was operated before the occurrence had been decided by the master. The C/O or 3/O, although concerned about the operating procedures, did not question the master's decision. The lack of assertiveness on the part of the 3/O, not atypical in maritime operations, allowed the vessel to be operated according to the situational awareness of only the master. BRM principles advocate that crew members share information to ensure as much as possible that all relevant factors are taken into account in the decision-making process; such a principle is a catalyst for other officers to be assertive when faced with a perceived unsafe situation. The crew of the GRIFFON, including the master, had not been trained to practise the principles of BRM. In the absence of assertive inquiry on the part of the C/O or 3/O, the master did not reexamine his operating decisions. 2.2.3 CAPTAIN K 2.2.3.1 Operation The fishing vessel was not operating with a designated look-out, and may not have been sounding fog signals. The two crew members were in their bunks and could be expected to be no more fatigued than the operator; one of them could have been designated as look-out. If the radar had been in operation, it is probable that the operator would have had early knowledge of the approaching vessel and, if sensing a potential collision situation, he could have called the GRIFFON on VHF R/T to agree on avoidance action. 2.3 Distractions to Navigation on the GRIFFON 2.3.1 Use of Cellular Telephone The location of the cellular telephone on the bridge of the GRIFFON, adjacent to the chart navigation area and next to the starboard radar, was such that a person answering the phone was a physical intrusion in the navigation area. Conversations are a distraction when important navigation decisions are being formulated based on information read from the adjacent radar set and other instruments. Such was the situation when the GRIFFON departed buoy N. The 2/O stated that, while the C/E was talking on the phone, he had indicated a target on the heading marker to the 3/O who was adjusting the vessel on to a new course. A distraction may have resulted from the casual conversation. 2.3.2 Essential Crew on the Bridge On completion of the cellular telephone call, there was no operational requirement for the C/E to remain on the bridge. No particular useful information regarding ship navigation was provided by him, but his presence provided the opportunity for the other officers to engage in conversation. The C/O came up to the bridge but had no dedicated task before doing so. Once on the bridge, he nominally acted as look-out but also proceeded to join in the conversation. Under the critical operating circumstances such as those prevalent at the time, it is important that only personnel essential to the navigation of the vessel be on the bridge, and these individuals must know and diligently practise their precise responsibilities. 2.4 Traffic Awareness It is not known whether the CAPTAIN K heard any of the radio traffic that could have indicated that the GRIFFON was operating in the area. The initial advice by the GRIFFON was on VHF channel 82A, a channel unlikely to be monitored by the fishing vessel. Therefore, it is unlikely that the CAPTAIN K heard the Notship put out by the Sarnia and Toronto CGRS from which the vessel might have deduced that a CCG buoy tender was working in the area. Not being in a mandatory VTS zone, the GRIFFON was not otherwise reporting her movements. The GRIFFON was not monitoring, nor was she required to be, either VHF R/T channel 18, the inter-fishing vessel channel for the area, or channel 7A, the channel used by the CAPTAIN K to communicate with the fish plant and, therefore, did not overhear any transmissions involving the CAPTAIN K. In the absence of crew briefings about the operational environment, of security calls, and of monitoring of other radio channels, both vessels lacked situational awareness of vessel traffic in the area. 2.5 GRIFFON Radar Operation 2.5.1 Sea Clutter Return There was some sea clutter reported on the radar which could be a probable explanation for the GRIFFON not being aware of the presence of the CAPTAIN K and for a small intermittent echo ahead not being tracked outside the clutter area. Once inside the sea clutter, it would have been virtually impossible for such a target to be noticed. 2.5.2 Radar Plotting It is difficult to understand how vital evidence, such as the plot on the reflection plotter, was erased. The fact remains that an approaching steel fishing vessel, known to be a typical radar target for her size, was not tracked on the radar. Although the OOW stated that he spent a considerable amount of time at the radar before the collision, this suggests that proper use was not made of the radar in that no continuous and dedicated search for targets was undertaken or no proper radar plotting was made of the echoes seen. The other possibility is that the radar controls were not correctly adjusted, but this is unlikely because small well-head marker buoys were seen. There are several discrepancies in evidence, one being the statement that the four well-head markers were plotted to move reciprocally on a relative plot, but the inbound target off Long Point was plotted as stationary. The initial testimony by the OOW indicated that he thought that the echo off Long Point (at a time presumed to be about 1255) was inbound but no plots were made to establish this. An inbound target cannot be presumed to be stationary. His later testimony indicates that the target was only seen a few minutes before the collision. The recollection plot, as submitted several hours after the accident, is inconclusive, but if one assumes that the echo off Long Point was observed at 1250, then it is possible that this echo was that of the CAPTAIN K. 2.6 GRIFFON 1300 Logged Position There is no appreciable current in Long Point Bay. The 1300 position, as logged aboard the GRIFFON, at 200 x 6.7 M off Bluff Point, would indicate that in order to reach the sink position of the CAPTAIN K or the collision position, as reported on the reporting form, the GRIFFON would have had to average 15.3 or 15.75 kn respectively. Based on a distance of 6.4 M off Bluff Point, the speeds would have had to be 15.75 or 16.2 kn respectively. Based on distances of 6.4 and 6.7 miles off Bluff Point and the collision position as originally noted by the GRIFFON (4236'N,8002.7'W), the vessel would have had to average either 18.45 or 18 kn. Since the top speed of the GRIFFON is 12.5 kn, the positions given in the evidence are unexplainable. 2.7 GRIFFON Actions of Helmsman Confronted by the rapidly developing dangerous situation, the helmsman did not have the experience to judge properly which alteration to make; his initial training may have given him the inclination to go to starboard when in doubt. Had the C/O and 3/O detected the fishing vessel first, the same decision may have been made by either one. However, if the officer had noticed the propeller wash of the CAPTAIN K in the astern mode and/or the lack of a bow wave, he may have altered to port to avoid the fishing vessel. On balance, it is not possible to state if the avoidance action of the GRIFFON was correct. 2.8 Radar Reflectors As a vessel of less than 20 m in length, the CAPTAIN K should have been equipped with a passive radar reflector. In this case, tests showed that little difference could be observed in the radar return from a fishing vessel with or without a radar reflector, and with or without a metal fishing signal. However, because of the widely different operating conditions possible on the day of the occurrence and at the time of the tests, it is not possible to say if a radar reflector would have enhanced the radar image of the CAPTAIN K. 2.9 Non-identification of the CAPTAIN K on the Radar Aboard the GRIFFON The recollection plot, stated to be for approximately 1250 and considered to be at about 1255, shows an echo observed off Long Point. This echo was never re-acquired and was presumed by the OOW at that time to have been stationary, but inbound in earlier evidence. The fact that the collision occurred at 1320 and that the GRIFFON was running at about 12 kn would put her some four miles north of Long Point at the time of the recollection plot. Meanwhile, the CAPTAIN K was stated to have been rounding Long Point at about 1200/1215 with the possibility of stopping to look for more fish. She may have been stationary until about 1245/1255 and under way northbound thereafter, which could account for the stationary and inbound evidence of the OOW of the GRIFFON. If the CAPTAIN K had been under way at full speed off Long Point at 1250, she would have reached the collision position in the time available (30 minutes) at that speed. The fact remains that the echo off Long Point was never properly identified and could have been that of the CAPTAIN K. Since the second radar and defruiter were not switched on, this second aid to navigation was not available to detect the CAPTAIN K. 2.10 Collision Angle The damage sustained by the CAPTAIN K indicates that the GRIFFON struck the fishing vessel at an approximate angle of 60 to 80 to the fore-and-aft line. The courses steered by the CAPTAIN K before the collision are not known; however, if the fishing vessel was steering a course close to that from a position off Long Point to the sink-position, the angle of approach between the two vessels would have been approximately 20. This apparent discrepancy in collision angle can be explained by the bow wave of the GRIFFON sheering the fishing vessel to starboard before impact and, to a degree, by the canting of the CAPTAIN K's stern to port under full-astern engine movement with a right-handed propeller. 2.11 CAPTAIN K Subdivision As the vessel was under 15 GRT, she was not required to have, and did not have, watertight bulkheads. If she had been so fitted, the CAPTAIN K may not have sunk so rapidly. 2.12 Safety Management System (SMS) 2.12.1 GRIFFON Notwithstanding that the CCG is the operator of a large government fleet, a SMS policy had not been introduced at the time of the collision. A SMS policy may have clarified the operational reporting role for the master and may have ensured that the appropriate navigational procedures were instituted as a result of lessons from a previous audit. 2.12.2 CAPTAIN K Although a formal written SMS policy would not be expected for such a vessel, similar principles apply. The operator, in requesting that the radar be repaired, had displayed the necessary responsibility toward safety; however, the owner, by not ensuring that a vital navigational aid was operational, did not provide the operator with the support that would be expected in a well run SMS. 2.13 Medical Information 2.13.1 Status of the GRIFFON's Master Twice during 1990, the master had responded strongly to stressful events with episodes of emotional instability and symptoms such as insomnia. For a month, in September 1990, he was treated with antidepressant medication. On 19 October 1990, during the master's routine assessment by a designated physician, when the issues of stress, depression and treatment were considered, he was declared medically fit. In March 1991, a few days before the collision, his file was reviewed by the HW physician who had personally known and examined the master previously, and, in his view, the master had responded well to medication. At that time, the October 1990 assessment of medical fitness for duty was formally approved. Operational stressors were reduced during the winter months when the GRIFFON was laid up at Amherstburg, Ontario. By the date of the collision, the GRIFFON had been fully operational for approximately two weeks and the duties and pace of activities were similar to or exceeded those that had existed when the master had previously sought medical attention. The master's medical condition had the potential to affect ship safety; but, due to a lack of communication and, to some extent, inadequate resources, the programs available were not utilized by the master nor was he referred for counselling. 2.13.2 The Occupational Health Program The principal objectives of the HW occupational health program were not achieved due to the lack of communication between the physicians treating the master and those performing the examinations for fitness for duty. The latter physicians did not determine whether it was appropriate for the master to continue to work while on antidepressant medication. Discussion between the family physician and the designated physician, especially over the suitability of continued employment in an environment that apparently was provoking stress- related symptoms, did not occur. Ideally, in a pro-active program, personnel from a variety of disciplines can be coordinated by the medical officer to provide such services as workplace hazard assessment, training, wellness programs and medical counselling. 2.13.3 Canadian Coast Guard (CCG) Management CCG management did not regard the master's initial period of depression, resulting from the cancellation of his vacation leave, seriously. They did not request EAP counselling. However, they did not know of any stress recurrences, nor of the treatment with antidepressant medication while on duty. At least in the context of the events preceding the collision, the CCG appears to have been a relatively passive recipient of service from HW. No communication occurred with those responsible for the Occupational Health Program, nor was there any between EAP and HW. 3.0 Conclusions 3.1 Findings 3.1.1 GRIFFON The master endeavoured to complete a buoy program in daylight and before weather deterioration while also considering the requirement to minimize overtime. In visibility reduced by fog, the vessel was steaming at full speed, averaging 11 knots (kn) since placing buoy N. Fog signals were not sounded. A radar target observed off Long Point was not properly identified or monitored. There was no systematic blind pilotage regime in place. Course adjustments were not entered in the rough bridge logbook. The position logged for 1300, 18 March, may be in error. The chief officer (C/O) assumed a temporary role as look-out but this role was neither formalized nor properly carried out. The vessel was operating with only one of two radar displays in use. Use of the cellular telephone, installed on the bridge, invited intrusion into the bridge navigational area. Navigation routine was interrupted by a cellular telephone call and by the recipient remaining on the bridge after the call. Three officers on the bridge were engaged in casual conversation before the collision. The radar target of the CAPTAIN K was not observed. The helmsman was the first person on the bridge to visually sight the approaching fishing vessel. The helmsman took emergency alter-course action before he could be instructed by an officer. No immediate report of the collision was made. 3.1.2 CAPTAIN K There was no dedicated look-out. The radar fitted aboard had not been operational for some six months. The operator was engaged in navigating and manually steering his vessel in reduced visibility. There was only one exit from the wheel-house, which escape route was completely blocked by the damage of the impact. A radar reflector was not exhibited. The engine was at full astern at the time of the collision. No watertight bulkheads were fitted, nor were any required by regulation. 3.1.3 Vessel Traffic Services (VTS) 1. There was no VTS system in operation in Long Point Bay on that day. 3.1.4 Canadian Coast Guard (CCG) Fleet Systems No consolidated Safety Management System (SMS) was in place. No formal Bridge Resource Management (BRM) training program was in place. The master had been on indefinite medical leave and had returned to duty without being examined by a physician with the authority to approve his return to duty. In September 1990, the master had been treated for approximately one month with antidepressant medication, during which time he continued his duties on board without the knowledge or approval of the designated medical authority. On 16 October 1990, he was declared medically fit, and a few days before the collision, the Health and Welfare Canada (HW) physician was of the view that the master had responded well to medication. It takes several weeks to medically clear a new employee for employment, and the helmsman had not been sent for the required pre-employment medical examination. There was no liaison between the CCG supervising HW physician and the CCG Employee Assistance Program (EAP) counsellor. There was no policy in place for a formal operational/medical review before re- employment of a person who had been on medical leave because of stress-related problems. There was no policy in place for formal operational/medical monitoring of a ship's crew member who was on a regimen of prescribed drugs. There was no policy in place regarding what action should be taken if officers disagreed with the master's standards of operation of a vessel. 3.2 Causes The GRIFFON, operating at full service speed in reduced visibility, without the use of fog signals, did not correctly identify a radar target ahead of the vessel and take collision avoidance action before the target entered the area of sea clutter. Contributing to the collision was the fact that the CAPTAIN K was operating without a serviceable radar. 4.0 Safety Action 4.1 Action Taken 4.1.1 Use and Location of Cellular Telephones Since the use of cellular telephones on the bridge can greatly detract from the concentration and attention required of the watch personnel for vital navigational duties, a TSB Marine Safety Advisory was forwarded to the Canadian Coast Guard (CCG) in 1992 advising of the need to establish guidelines on the installation and use of cellular telephones or other optional communication equipment aboard Canadian vessels. Subsequently, the CCG issued Fleet Circular No. FSC2-92 relating to the use and location of cellular communication equipment. The commanding officers of all CCG fleet vessels were instructed to establish guidelines detailing the use of cellular telephones and other optional communication equipment on the bridge, so that their use will not interfere with the safe navigation or operation of the vessel. Further, the CCG issued Ship Safety Bulletin No. 7/92, Guidelines Involving the Use of Radiocommunication Equipment Fitted on the Ship's Navigation Bridge. The Bulletin suggests that communication facilities for personal calls be provided in areas other than the navigation bridge. Where such alternative arrangements are not possible, personal and business calls should be kept as brief as possible to avoid distracting the bridge personnel from their duties. 4.1.2 Radar Reflectors on Small Vessels In view of the increased risk of collision in conditions of reduced visibility and since a passive radar reflector can improve the detectability of small vessels, a TSB Marine Safety Advisory was forwarded to the CCG in 1992 to remind operators of small vessels, particularly fishing vessels, of the requirements for passive radar reflectors laid down in the Collision Regulations. Accordingly, the CCG issued Ship Safety Bulletin No. 4/92 on The Fitting of Radar Reflectors on Small Vessels (an updated version of Bulletin No. 3/81, Radar Reflectors - A Safety Device for Small Vessels). The latest Bulletin reminds small vessel owners/operators of the importance of using radar reflectors. It states that small vessels operating in reduced visibility have been run down or swamped by larger vessels because of a lack of detection. It emphasizes the particular importance of radar reflectors for small fishing vessels since many operate in all types of weather, by day and night. It also indicates that small vessel owners/operators wishing to build a radar reflector to meet the required standard can obtain plans from their regional Ship Safety offices. 4.1.3 Notice to Shipping/Security Calls In view of the need to make local fishing communities aware of CCG fleet activities in fishing areas, a TSB Marine Safety Advisory was forwarded in 1992 advising the CCG to explore means of communicating information to the Port Dover and other fishing communities of CCG activities in their area. The CCG, recognizing the national implications, discussed this aspect of marine safety at regional Canadian Coast Guard Marine Advisory Council meetings and solicited ideas and suggested improvements from marine and fishing industry representatives. 4.1.4 Non-essential Personnel on Bridge Another TSB Marine Safety Advisory in 1992 advised the CCG to consider measures to limit the presence of non-essential personnel on the bridge. As a result, Fleet Circular No. FSC2-92 (described in 4.1.1) also instructed the commanding officers of all CCG fleet vessels to include in their Master's Standing Orders guidelines restricting the presence of non-essential personnel on the bridge, in the engine-room, control room, winch control room and any other critical operating areas. 4.1.5 Radar on Small Fishing Vessels Recognizing the safety value of radars as collision avoidance instruments, a TSB Marine Safety Information (MSI) letter was forwarded in 1992 apprising the CCG of the condition of the radar aboard the CAPTAIN K. The MSI discussed the importance of proper installation, maintenance and correct operation of radars on smaller vessels. Subsequently, the CCG promoted this aspect of marine safety through its Search and Rescue Prevention Program as well as its Commercial Fishing Safety Advertising Campaigns. 4.1.6 Bridge Resource Management (BRM) Following this occurrence, the CCG amended several sections of the Coast Guard Fleet Orders (CGFO). A new CGFO 209.00 on Nautical Practices and Procedures was added to the existing CGFO which, inter alia, addresses more effective bridge safety procedures between masters and officers of the watch (OOWs). Further, it is understood that the CCG has purchased BRM training materials to train its CCG fleet personnel. The first BRM training session for CCG fleet personnel took place in 1994 and follow-up training is continuing. 4.2 Action Required 4.2.1 Medical Fitness for Safety-sensitive Positions In July 1990, the master of the GRIFFON returned to work after being off for several weeks due to stress and stress-related symptoms. A couple of months later, he was treated by his family physician with a month-long course of an antidepressant medication. The Health and Welfare Canada (HW) occupational medical officer was not notified of this diagnosis and treatment, and the master continued his duties aboard the GRIFFON while under the medication. The CCG management knew about the master's initial stage of depression; however, apparently neither the management nor the Transport Canada (TC) Employee Assistance Program (EAP) officials were aware of the master's subsequent medical assessment and treatment. Poor health can affect physical, physiological, and psychological performance, and the use of certain prescribed drugs and over-the-counter medications can also impair an individual's performance, especially in the aspects of judgement, reaction time, and vigilance. As a result, some industry segments have recognized the need for regulations and policies regarding the medical fitness of persons in safety-sensitive positions. For example, Canadian aviation pilots and air traffic controllers are required under the Canadian Air Regulations to undergo medical examinations by designated physicians and to advise their other physicians that they are licenced pilots or controllers. In turn, these physicians must inform a designated medical advisor of any condition of the patient if, in the opinion of the physician, such medical condition is likely to constitute a hazard to aviation safety. In the United States, following a collision between a U.S. Coast Guard cutter and a freighter, the National Transportation Safety Board (NTSB) recommended standards for the taking of medication by watchstanders on U.S. Coast Guard vessels to ensure that the medication does not impede the individual's ability to perform his/her duties5. Further, as a result of the grounding of a passenger-car ferry, the NTSB recommended that ships' officers on U.S. passenger vessels be required to report on any medication taken so that a medical determination of its effect on an individual's ability to perform watchkeeping tasks can be made6. In Canada, the current medical policy and standards for CCG personnel were established by HW (now Health Canada). Under the policy, medicals are conducted at specified intervals by designated physicians to determine, inter alia, that CCG employees are fit to work without a detriment to safety. Also, special medical evaluations can be arranged through the EAP if work performance is thought to be suffering because of possible health problems. In this occurrence, extenuating circumstances resulted in limited dialogue between the CCG HW physician in Toronto and the TC EAP officer concerning the master's medical condition. Notwithstanding these circumstances, there are no formal procedures in the Canadian marine industry that would have ensured that a person capable of determining the master's ability to perform his duties would have been informed of his medical condition. Like the master on the GRIFFON, other mariners may unknowingly be jeopardizing safety during the conduct of their duties because a medical condition or medication is impairing their performance. The Board found no link between the master's medical condition or his medication and this accident. Nevertheless, the Board is concerned about the lack of a formal mechanism to identify and monitor persons who are not medically fit for duty and who occupy safety-sensitive positions such as ships' officers and pilots. In view of the lack of liaison between the HW physician and the TC EAP counsellor, the lack of communication between the family physician and the designated HW physician, the lack of formal operational monitoring of a ship's crew member in a safety-sensitive position who was on a regimen of prescribed drugs, and the lack of formal operational medical review before re- employment of a person returning to safety-sensitive duties following stress-related medical leave, the Board recommends that: The Department of Transport, in cooperation with Health Canada and the Canadian Coast Guard, define policies and procedures to ensure that personnel returning to safety-sensitive duties following any medical treatment are fit for those duties. 4.3 Safety Concern 4.3.1 Collision Avoidance and Bridge Operating Procedures The International Chamber of Shipping (ICS) has long recognized that a failure to keep a good lookout and weaknesses in bridge organization were main causes of marine collisions and groundings7. This observation is supported by Canadian marine occurrence statistics. During the 10-year period between 1984 and 1993, nearly two-thirds of the vessel collisions in Canadian waters were attributable, at least in part, to procedural deficiencies and inadequate watchkeeping practices. In this occurrence, the officers on the GRIFFON, although properly certificated and endorsed, did not practice basic seamanship, nor perform established collision avoidance procedures. The TSB has recently released two other reports on major occurrences (one on the collision between the TENYO MARU and the TUO HAI (TSB Report No. M91W1051) and the other on the occurrence involving the IRVING NORDIC in the St. Lawrence River (TSB Report No. M91L3012)), in which inadequate watchkeeping practices and a failure to observe collision avoidance procedures were cited as contributing factors. The Board is concerned that, in spite of the presence of qualified officers on the bridge, non- adherence to well-established navigational procedures continues to be a significant factor in Canadian marine occurrences. Therefore, the Board will place increased emphasis on the marine occurrences involving a failure to follow established navigational procedures and focus on the underlying conditions to this divergence from normal behaviour.